Tees, Esk and Wear Valleys NHS Foundation Trust

4. Mrs R complains about the Trust following the death of her brother-in-law Mr A in December 2020.

5. Specifically, she complains the Trust:

• failed to explain the significant risks of drinking alcohol when taking clozapine, pregabalin and zopiclone. She said as a result, Mr A was denied informed consent, which was a profound breach of the duty of candour.

• failed to complete a plasma test despite Mr A’s ‘classic’ symptoms of chronic toxicity, and its care planning was ‘dangerously inadequate’. This meant that Mr A’s deteriorating condition went unmonitored.

• confirmed that its CITO IT system cannot track clozapine side effects. She said that continues to present a live systemic patient safety risk.

• withheld records, its serious incident report, and its datix report, and failed to confirm if it reported Mr A’s death to the Medicines and Healthcare products Regulatory Agency (MHRA). She said this caused a gap in her understanding of what happened to Mr A before he sadly died and presents a further risk to patient safety.

• failed to address an agreed terms of reference and poorly handled her complaint. By doing so it bypassed questions about staff training and its duty of candour and displayed systemic maladministration.

6. Mrs R says that the cumulative actions of the Trust have had a profound impact on her and her husband. Mr A’s death was devastating and the ongoing battle with the Trust for information so they could understand what happened has caused severe emotional distress, upset and frustration. She said pursing the complaint has caused her husband anxiety and further distress as he is unable to support her in seeking the answers around Mr A’s death.

7. Mrs R wants the Trust to answer her questions, apologise where she has asked it to, implement service improvements, and provide a financial remedy for the impact of its failures.

10. Where someone tells us an organisation has made mistakes leading to physical or psychiatric harm, they may have a legal route of clinical negligence available to them. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mrs R to understand her circumstances and the outcomes she wants, given that she describes physical harm as a result of the actions of the Trust. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

11. Mrs R has explained to us that she has an ongoing legal claim against the Trust. She said this is a claim for private compensation and is likely to be a nominal award. In our conversations, Mrs R told us that the legal action will not address some issues about care and treatment, nor the complaint handling demonstrated by the Trust. She is concerned about ongoing patient safety risks and says these remain while the legal action is ongoing.

12. In terms of the clinical matters Mrs R raised, there is ongoing legal action underway, and we consider that, as this is ongoing and it can achieve the financial remedy she is looking for, it is reasonable that Mrs R should continue with this.

13. For the complaints about the Trust’s investigation and complaint handling, there is no legal recourse for these concerns, and we have considered whether we can look at these matters now. At this point, we can see it would not be appropriate for us to consider these concerns until the legal action is complete. This is because these matters are linked to those currently being explored through the legal process and so we do not know how the ongoing legal action will impact Mrs R’s complaint and the outcomes she seeks. We acknowledge her concerns about ongoing patient safety risks and her view that there are underlying issues that have not yet been addressed.

14. If her circumstances change and this means that it is no longer reasonable to pursue legal action or, if when the legal action is complete, there are concerns or outcomes that the court has not considered, Mrs R could return to us at that time. If she decides to return to us, we advise her to do so as soon as possible so there are no barriers resulting from our time limit.

15. We appreciate this complaint is very important to Mrs R. We hope we have clearly explained how we have thought about her complaint in reaching our decision in this case.

1. We have carefully considered Mrs R’s complaint about the Trust and the clinical care it provided to her brother-in-law Mr A before his sad death in December 2020. We can see she is in the process of legal action against the Trust, and it is reasonable for her to pursue that course of action for the financial remedy she is looking for.

2. We will not consider at this time Mrs R’s concerns about the Trust’s complaint handling and outcomes that the courts cannot achieve for her. This is because it would not be appropriate for us to do so until the legal action is complete.

3. We were sorry to hear of Mr A’s sad death and the deep impact this had on Mrs R, her husband Mr R, and their family. We thank her for bringing her concerns to us and sharing their experience with us.